According to Atul Gawande medicine lies at “the messy intersection of science and human fallibility”. Named as one of the world’s most influential thinkers by Time in 2010, Gawande is a world renowned surgeon and storyteller who, in this year’s Reith Lectures, has sought to explore the nature of modern medicine and its future.
The Reith Lectures began in 1948 and each year a leading figure is invited to further public understanding and debate on key issues through a radio broadcast. Gawande is well-placed to deliver on such a big global theme, and one that spans public health, the delivery of medicine and his most recent work on the relationship between medical culture and how we die. His central message is that we need to rethink medical practice such that it becomes concerned with the wellbeing of patients and not just their health; to focus on caring and not simply curing – which can be an unrealistic goal for patients with chronic illnesses.
The first three lectures – Why do Doctors Fail, Century of the System and The Problem of Hubris – were organised around a central case. In the second lecture the case concerned a young child who drowned in a frozen pond. She was saved by a complex set of interventions including reheating her blood slowly, ECMO machines and life support.
On occasion Gawande’s use of case studies was a little frustrating, because the time devoted to recounting these tales seemed to sometimes take precedence over making his points clearly. Gawande appeared to be suggesting that medicine should consider the body a system or a set of systems, and many medical technologies – notable respirators and ECMO machines (which oxygenates the blood) – can become part of these systems and support their functions, at least for a time.
Getting the most out of modern medicine means adopting a systems approach, both in the sense of clinical organisation and how treatments take place. Gawande recommends we systematically consider reorganising everyday medicine to ensure “best practice”. This is not just a matter of treatment protocols but of creating the right clinical context as well as administrative and inter-professional environment. As director of the World Health Organisation’s programme to reduce surgical deaths worldwide, Gawande developed the use of surgical checklists – when used properly a checklist is an institutionalised and systematic approach to minimising errors that could have been prevented.
But, as Gawande discussed in his first lecture, doctors do fail – scientific knowledge is not infallible, meaning that some errors are unavoidable and even necessary. It is important that we have a realistic grasp of what modern medicine can offer. Gawande suggests we have been fooled by the simplicity of penicillin. Such magic bullets are medical rarities. Most treatments bring risks and costs as well as benefits. And as our medical knowledge develops, treatments tend to become more complex, not less, and patients require more support, not less.
In his third lecture, The Problem of Hubris, Gawande highlighted some of the misguided views doctors and, we might add, the public have about the power of medicine. Many contemporary innovations, from screening programmes to giving birth in hospital, can bring great benefits but, when improperly implemented, they also carry distinctive costs. Screening can lead to misdiagnosis and overtreatment, while medicalised childbirths have resulted in clinically unjustifiable variations in rates of cesarean sections. As Gawande has it, we have trouble ensuring that we use technology wisely.
Across the lectures it was clear that Gawande’s patient was healthcare systems themselves. As a writer and fan of narrative medicine - the idea that healthcare professionals should appreciate the fact an illness and it’s treatments, are not simply medico-biological events but part of a patients biography with which they should engage - Gawande’s lectures can be understood as offering various diagnostic tales. Most suggest that the means of medicine – or, at least, the way we currently make use of them – have become malformed. This is because we mistakenly take “health” and “cure” as being the end goals when, in fact, they should be “care” and “well-being”. Gawande’s prescription is, however, to expand and develop healthcare and in particular the systematic way we care for health.
There is a lot which is positive in Gawande’s message and others have offered similar perspectives. For example Raymond Downing, an American Family Doctor who has experience of working in Africa - particularly Kenya - and who has previously written about modern healthcare, has developed the term biohealth as part of his criticism of modern medicine’s singular focus on the biological. However he goes further in arguing that health itself has become medicalised and that our lives are increasingly organised and managed by social systems that originate in the concerns of healthcare professionals and other such experts.
In light of these more provocative claims we might, given the nature of medical hubris Gawande outlined, question the degree to which we want medicine to take the lead in systematically restructuring our lives. We might also consider the political dimension of medical and healthcare expertise. As Gawande presents it, expanding medicine’s concerns for health to encompass well-being is in the interest of patients as it will be the patients values that are promoted.
However, our own values are not entirely independent of the ends of medicine. In many areas of our lives the ideals of medicine have become our own. Of course there are positive as well as negative consequences – we join gyms in the name of health but then feel guilty when we fail to go as often as we should. The imperatives of medicine increasingly structure the way we lead our lives. As such, if medical practice becomes reorientated towards “well-being” rather than health, then this should be understood as a development in its socio-political function. In this light Gawande’s Reith Lectures must be taken as an early contribution to a bigger discussion regarding the connection between modern medicine and the art of living.